Provider Demographics
NPI:1598949141
Name:NERYAEV, DIANA (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:NERYAEV
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8022 192ND ST
Mailing Address - Street 2:HOUSE
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11423-1043
Mailing Address - Country:US
Mailing Address - Phone:917-517-3950
Mailing Address - Fax:
Practice Address - Street 1:8022 192ND ST
Practice Address - Street 2:HOUSE
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11423-1043
Practice Address - Country:US
Practice Address - Phone:917-517-3950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-18
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048089183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1659904605Medicaid